T3 L3 Schizophrenia: clinical features

Question 1

What are neurosis disorders?

Answer 1

Anxiety disorders
Depressive disorders
Obsessive compulsive disorder
Adjustment disorders
Somatisation borders

Question 2

What are psychosis disorders?

Answer 2

Organic
Schizophrenia
Bipolar disorder
Depressive psychosis

Question 3

What is psychosis?

Answer 3

Illness characterised by loss of boundaries with reality & loss of insight with primary features of delusions & hallucinations

Question 4

What is a psychotic episode?

Answer 4

1 week duration of either delusions and/or hallucinations at significant severity

Question 5

What is a delusion?

Answer 5

Belief held firmly but on inadequate grounds, not affected by rational argument or evidence to the contrary.
Not shared by someone of similar age, educational, cultural, religious or social background

Question 6

What are some types of delusion?

Answer 6

Primary
Secondary
Persecutory
Of reference
Grandiose
Of guilt
Nihilistic
Of passivity

Question 7

Why do delusions occur?

Answer 7

Due to error of salience of attribution
Dopamine plays a role in motivation & reward. Excessive dopamine in these pathways could lead to the world seeming pregnant with significance

Question 8

Give some examples of delusions

Answer 8

Religious, persecution by devil
Persecution by authority figure / government
Controlled by implant
Responsibility for world tragedy
Followed by seagulls

Question 9

What is a hallucination?

Answer 9

Perception experienced in absence of external stimulus
In any sensory modality
Due to internal perception attribution error

Question 10

What is the most common type of hallucination in psychosis?

Answer 10

Auditory

Question 11

What did Esquirol do?

Answer 11

1838
Described course & prognosis of insanity & separated it from the diagnostic group of mood disturbances (melancholia) which had a better outcome.

Question 12

What did Kraepelin do?

Answer 12

1898
Defined dementia praecox with onset in adolescence of progressive, irreversible decline in mental function
Different forms: hebephrenic, catatonic, paranoid & simplex
Distinguished from manic depressive illness

Question 13

What did Bleuler do?

Answer 13

1911
Coined term schizophrenia with ‘splitting of the mind’ & described fundamental symptoms: abnormal associations, autism, abnormal affect, ambivalence

Question 14

What did Schneider do?

Answer 14

1946

Defined first rank symptoms pathognomic of schizophrenia

Question 15

What are the first rank symptoms?

Answer 15

In absence of organic disease signify schizophrenia
Auditory hallucinations
Somatic hallucinations
Thought insertion, withdrawal or broadcast
Passivity phenomena. Made acts / impulses / affect
Delusional perception
Found not to be inclusive of all subjects with schizophrenia

Question 16

What is the ICD 10 diagnosis of schizophrenia?

Answer 16

Minimum of 1 a-d or 2 e-h for at least 1 month
A) Thought echo, insertion, withdrawal or broadcast
B) Delusion of passivity or delusional perception
C) Running commentary hallucination or 2 voices discussing the patient
D) Persistent delusions of other kinds
E) Persistent hallucinations in any modality with accompanying brief delusions
F) Breaks in thought resulting in abnormal speech (incoherent, neologisms)
G) Catatonic behaviour (excitement, posturing, wavy flexibility, negativism)
H) Negative symptoms not due to depression or medication
In absence of an organic disorder

Question 17

What are some differential diagnosis?

Answer 17

Affective psychosis:

• Bipolar disorder
• Depressive psychosis
• Schizoaffective disorder

Organic psychosis:

• Epilepsy
• Infections
• Cerebral trauma
• Cerebrovascular disease
• Demyelination
• Neurodevelopmental disorders
• Endocrine
• Metabolic
• Immunological
• Acute drug intoxication
• Toxins
• Dementia

Personality disorder

Question 18

What are some signs of schizophrenia?

Answer 18

Bizarre appearance or behaviour
Self neglect
Social disturbance
Posturing
Clothing
Perplexity
Talking to themselves

Question 19

What side effects of medication are there that may present as schizophrenia?

Answer 19

Parkinsonian symptoms: tremor, rigidity, bradykinesia
Tardive dyskinesia including orofacial, athetosis, dystonias
Skin discolouration
Severe weight gain

Question 20

Describe the mental state examination in an acute syndrome

Answer 20

Appearance: preoccupied & withdrawal to restless & unpredictable
Mood: blunting of mood, disinhibition, perplexed, anxious
Disorder of thinking: vague, formal thought disorder, disorders of stream
Delusions: primary, secondary
Hallucinations: auditory, visual, tactile, olfactory, gustatory
Insight: impaired
Cognition: normal orientation & memory

Question 21

Describe the mental state examination in a chronic syndrome

Answer 21

Appearance: lack of drive & activity, social withdrawal, self neglect
Movement abnormalities: stupor, catatonia, abnormal movements & tone
Mood: blunting of mood, depression
Delusions: primary, secondary
Hallucinations: auditory, visual, tactile, olfactory, gustatory
Insight: impaired
Cognition: normal orientation but often cognitive decline

Question 22

What is the prevalence of schizophrenia?

Answer 22

0.2-0.7%

Question 23

What is the geography of schizophrenia?

Answer 23

Incidence up to 5X variation worldwide
Increased rate in migrants
More prevalent in urban than rural areas
Urban drift

Question 24

Describe the age of onset of schizophrenia

Answer 24

Male peak onset at 21-26

Female peak onset at 25-32

Question 25

What is the prognosis of schizophrenia?

Answer 25

Better outcome in 3rd world & with introduction of early intervention services
20% have complete recovery & off treatment
25% have persistent symptoms after first episode
>50% have relapsing remitting illness with some functional impairment between episodes
Recurrent episodes may lead to progressive deterioration
Suicide in 5-10%, particularly men within 3 years of onset

Question 26

What increases the likelihood of a good prognosis of schizophrenia?

Answer 26

Female
Married
Family history of affective disorder
Acute onset
Life event at onset
Early treatment
Affective symptoms
Good treatment response

Question 27

What decreases the likelihood of a good prognosis of schizophrenia?

Answer 27

Male
Single
Family history of schizophrenia
Premorbidly schizoid
Slow onset
Long duration untreated
Negative symptoms
Obsessions
High expressed emotion in the family
Substance misuse

Question 28

What effect does cannabis have on psychosis?

Answer 28

Increases risk
Impact of cannabis on developing brain is more potent
Familial liability for psychosis is expressed as differential sensitivity to cannabis
Chronic use sensitises to effect & increases vulnerability to psychosis